A lot is made of social determinants of health—for good reason—but many medical schools have yet to catch up with this defining feature of American life. To achieve health equity in the U.S., one physician expert says, there’s a new domain—“structural competency”—that must find its way into the curriculum.
“Why this moment to roll out the language of structural competency?” said Helena Hansen, MD, PhD, professor and chair of translational social science at the University of California, Los Angeles David Geffen School of Medicine. “We know the terrible statistics on the poor return on investment that we get for what we pay for health care in this country. And clinicians know that it's due to social and systemic factors. But they don't know what to do about it.”
In remarks recorded for the AMA Medical Student Section’s virtual gathering at the November 2020 AMA Sections Meeting, Dr. Hansen started by defining the concept.
“Structure highlights the need to shift the focus of our work as clinical practitioners above the focus of the level of the individual to institutions—clinical, educational, correctional, etc.—to communities and to policies that determine health,” she said.
“And then competency indicates the expanded scope of clinical intervention and responsibility that we would need to have in order to address health problems at those levels—above the level of the individuals,” she added. “That's critical for us as clinical practitioners, because … when we talk about an issue as a health problem, we tend to get a certain kind of audience,” in other words, policymakers.
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"We can't do much about structural drivers of health until we understand and can see how they are influencing our patient's health,” Dr. Hansen said of the first step in adopting a structural competency perspective. “Second, we need to take patient presentations and retool them away from a cultural interpretation [and toward] structural interpretation. How are structural drivers at play as opposed to individual beliefs and behaviors of patients, cultural beliefs and behaviors?”
The third step, she said, is observing and practicing structural intervention.
“We want to do things, rather than sit around and philosophize,” Dr. Hansen said. “We need many more opportunities for that in clinical education—to see one, do one, teach one.”
Humility is important too, she said. And so is patience.
Physicians “are not all all-knowing, and we don't have the full skill set that's necessary for structural intervention,” Dr. Hansen said, noting that many doctors are not trained in community organizing or policymaking, meaning that doctors need to collaborate with those who have other expertise. And it takes time to achieve structural change. “So it's not a matter of days, weeks or even months. It's really a matter of years. And we have to have that time frame in mind.”
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Dr. Hansen detailed some practical steps for working structural competency into medical school curricula.
Screen for social needs. These include legal aid, food and housing assistance. “Just putting questions about social needs into an electronic medical record, that prompts a practitioner when they're doing a patient assessment,” Dr. Hansen said.
Develop partnerships with community organizations. “These are organizations in the community that can support the recovery of patients in the clinic,” she added, noting that residents can then map these organizations for clinical teams to use in treatment planning.
Collaborate with stakeholders outside medicine. These include schools, law enforcement and urban planners.
Train physicians as policy advocates. “They can use their authoritative voices on health matters to reframe harmful policies—such as drug laws [or] mass incarceration—as a health issue,” Dr. Hansen said.
The video also features a presentation by Jessica Mitter Pardo, a fourth-year medical student at Touro University California, summarizing how her school has incorporated structural competency—including how it relates to the COVID-19 pandemic—into its curriculum.